Friday, September 21, 2012

Keeping Your Pockets Fuller with Out-of-Network Physical Therapy

As the owner of FLASH Sports Physical Therapy, LLC, I often am asked by prospective patients if working with an out-of-network physical therapist will cost them more money.  My response: "Typically, no.  And oftentimes, less money in the long run."  But how is this saving remotely possible?  How is shelling out $100 for a 60-minute treatment session less money out-of-pocket than if you work with an in-network physical therapist and pay your traditional co-pay?

Health insurance companies tell us that we will save money by staying in-network.  For many procedures, this statement is true.  For instance, if you undergo ACL reconstruction, you will owe less money out-of-pocket for a surgeon's time if he or she is in-network compared to out-of-network.  Ultimately, these savings occur because the surgery is a one-time procedure on a particular day that is not influenced by the final outcome.  In other words, the health insurance company will pay the surgeon the amount of the previously negotiated fee that is to be covered by them so long as the surgery is completed successfully; your out-of-pocket costs will be whatever your health insurance plan originally designated as your responsibility (may be a co-pay, coinsurance, payment towards a deductible, etc.)

Now, let us take a look at the costs associated with in-network and out-of-network physical therapy care for a minor Achilles tendon issue.  The patient is a male high school runner who has struggled with increased symptoms in his Achilles tendon for a little over a month whenever he attempts to run faster workouts.  He is on his family's health insurance plan, which is a HMO plan.....the Aetna Advantage HMO 30 plan (Pennsylvania) to be specific.  So, what happens if he works with an in-network physical therapist?

$50 co-pay per visit, 2x/week for 8 weeks (16 total visits) = $800 out-of-pocket (after the initial evaluation)

If he is lucky, he will spend 15 minutes working directly with the physical therapist (perhaps manual therapy techniques and patient education)....not because the physical therapist does not want to work longer with him but because he or she has to see two other patients in that same hour.  With whom will the patient work the remaining 45 minutes that he is in the clinic (during which he performs exercises)?  Most likely a physical therapy technician or aide, who is usually a high school or college student interested in the field.  The patient enjoys working with the technician but truly values his time spent with the physical therapist, so if we calculate the amount of money he is paying the physical therapist per hour, we determine that rate to be $200 per hour ($50 for 15 minutes of time = $200 per hour).  **Grand total = $800 dollars out-of-pocket for 240 minutes spent directly with the physical therapist, 720 minutes of exercise with physical therapy technician.

What happens if this same exact patient works with an out-of-network physical therapist?

$90 per visit (10% discount), 1x/week for 4 weeks (4 total visits) = $360 out-of-pocket (after the initial evaluation)

In this case, the patient will spend 60 minutes working directly with the physical therapist.  In my clinic, 50 of these 60 minutes most likely will be spent on performing manual therapy techniques to directly facilitate healing of the Achilles tendon.  The last ten minutes will be spent reviewing the patient's home exercise program (to be performed daily to 3-4 times per week, depending upon the situation) and educating the patient.  Also, if this patient is working with me, he will receive a 10% discount on all services since he is a high school runner.  The physical therapist's rate per hour is exactly what the patient already paid him: $90.  **Grand total = $360 dollars out-of-pocket for 240 minutes with the physical therapist, performing home exercise program on own

***Summary: Discounting confounding variables (possibility of biology of tendon healing requiring 8 weeks of rehabilitation instead of 4 weeks despite concentrated manual therapy time and/or skill level of physical therapist), working with an out-of-network physical therapist could save this patient both time and money.  He could spend less time at a physical therapy clinic for treatment sessions (12 fewer hours!) and could save $440.  And the possibility exists that he may recover more quickly!  (Note: Even in another out-of-network clinic that does not provide this discount, this patient could save $400.)

This cost analysis is based upon actual situations and outcomes with which I have been involved in my career as a physical therapist.  Certainly, it only is one example of what can happen, and not EVERY patient will save money by working with an out-of-network physical therapist, but I have observed that quite a few will do so.  In terms of PPO plans, out-of-network physical therapy benefits may differ from one plan to the next....but in MOST cases, the savings will be even more substantial than that of a HMO plan, particularly if the individual or family has hit the yearly deductible.  So, the next time that you require the services of a physical therapist, take a close look at your health insurance plan and crunch the numbers.  You might be surprised as to what you discover.....and how much fuller your pockets are after successfully completing your course of therapy with an out-of-network physical therapist.


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